Table Of ContentDepression and Bipolar Disorder
Family Psychoeducational Group
Manual
Therapist Guide
Christina Bartha, MSW, RSW
Kate Kitchen, MSW, RSW, LISW
Carol Parker, MSW, RSW
Cathy Thomson, MSW, RSW
Centre
for Addiction and
Mental Health
Centre de
toxicomanie et
desante mentale
Depression and Bipolar Disorder
Family Psychoeducational Group Manual
Therapist Guide
Christina Bartha, MSW, RSW
Kate Kitchen, MSW, RSW, LISW
Carol Parker, MSW, RSW
Cathy Thomson, MSW, RSW
CAMH Development and Design Team for this manual:
Evelyne Barthes
Christine Harris
Caroline Hebblethwaite
Eva Katz
Nancy Leung
Norman Liu
Sue McCluskey
ISBN 0-88868-399-5
Printed in Canada
Copyright © 2001 Centre for Addiction and Mental Health
With the exception of the handouts, no part of this work may be reproduced or transmitted in any form or by any means elec-
tronic or mechanical, including photocopying and recording, or by any information storage and retrieval system without written
permission from the publisher — except for a brief quotation (not to exceed 200 words) in a review or professional work.
The handouts may be photocopied and distributed for use with clients. This licence is limited to the individual purchaser, for use
with the purchaser's own clients and patients and does not extend to additional therapists or practice settings. The licence does
not grant the right to reproduce these materials for sale, redistribution or any other purposes (including but not limited to books,
pamphlets, articles, video or audiotapes and handouts or slides for workshops or lectures). Permission to reproduce these mate-
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A World Health Organization Centre of Excellence
ACKNOWLEDGMENTS
Dr. Joel Raskin
Dr. Sagar Parikh
Dr. Robert Levitan
Susan Dickens, MA
Theresa Knott, BSW
Families who participated in the group series
REVIEWED AND MADE RECOMMENDATIONS FOR TRAINING
Louise Jablonski
Dave Foster
MANUAL REVIEWERS
Annabel Bassin
Sheila Porter
Barb Tiessen
Ian Waters
Charmaine Williams
iii
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CONTENTS
Acknowledgments iii
Introduction vii
Use of This Manual xii
GROUP 1 Introductions and Overview 1
Section 1: Leader's Introductions, Welcome and Preview of Group 5
Section 2: Members' Introduction 7
Section 3: Overview of Mood Disorders 9
Section 3a: Overview of Depressive Disorders 11
Section 3b: Overview of Bipolar Disorder 21
GROUP 2 Medical and Psychosocial Treatments 31
Section 1 a: Medical Treatments — Depression 35
Section 1 b: Medical Treatments — Bipolar Disorder 41
Section 2: Psychosocial Treatment Options 49
GROUP 3 Stress Management for Family and Caregivers 55
Section 1: How Has Your Life Been Changed by Your Relative's Illness? 59
Section 2: How Do You Recognize Stress in Yourself? 63
Section 3: Coping Strategies 65
Section 4: Relaxation Techniques 67
GROUP 4 Communication Strategies 69
Section 1: Effective Communication and Common Communication Problems 73
Section 2: Effective Communication Skills 77
Section 3: Leader's Role-Play of a Common Communication Problem 81
Section 4: Participants' Role-Play 83
Section 5: Communication with Your Support Network 85
Section 6: Talking with Children about Their Parent's Mood Disorder 87
GROUP 5 Problem Management 89
Section 1: Review of Communication Strategies 93
Section 2: Introduction of Problem Management 95
Section 3: How to Choose a Problem 97
Section 4: Using Brainstorming to Solve Problems 103
Section 5: Putting Brainstorming to Work 105
Section 6: Review and Wrap-Up 109
GROUP 6 Crisis Management 111
Section 1: Review of Problem Management 115
Section 2: Introduction to Crisis Management 117
Section 3: "What Crisis Have You Had to Deal With?" 119
Section 4: Strategies for Handling a Crisis 121
Section 5: Behaviours That Should Not Be Tolerated 127
V
GROUP 7 Working with the Medical and Legal Systems 129
Section 1: Emergency Action Plan 133
Section 2: Developing an Emergency Action Plan 135
Section 3: How to Work with the Medical and Legal Systems 137
GROUP 8 Summary and Planning for the Future 147
Section 1: Review of Groups 1 to 7 151
Section 2: Community Resources 153
Section 3: Looking to the Future 155
Section 4: Sharing Observations and Feelings 157
Afterword 159
References 161
APPENDICES 163
Appendix 1 Sample Brochure 165
Appendix 2 Mood Disorders Screening Form 167
Appendix 3 Intake Form 171
Appendix 4 Satisfaction Form 179
Appendix 5 Glossary 181
Appendix 6 Out of the Ashes of Mental Illness...A New Life 185
Appendix 7 Handouts - English 193
Appendix 8 Handouts - French 263
VI
INTRODUCTION
This group manual for therapists provides a framework for the delivery of an eight to 12-week series for fam-
ilies who require information and support in dealing with bipolar and depressive disorders. The manual
includes process notes, lecture materials and content for eight to 12 educational sessions, and handouts for
group participants.
The manual is written for clinicians/group therapists who have previous training and experience in facilitating
clinical group process but who also require the content and structure provided in the manual to meet the spe-
cialized needs of this group.
The group program aims to provide the following:
1. Information and education
To provide up-to-date, empirical information about the etiology and treatment of mood disorders
2. Practical coping strategies
To provide family members with practical strategies to deal with the behavioural symptoms associated with
these disorders
3. Strategies for reducing isolation and providing support
To provide a supportive environment where family members can share the painful feelings triggered by
these situations and receive support and empathy from other people dealing with similar circumstances. The
group is intended to have a therapeutic effect on family members; however, it is not a traditional group
psychotherapy experience.
HISTORY OF THE MANUAL DEVELOPMENT
This manual was developed as part of a three-year project in the Mood and Anxiety Disorders Program at
the Centre for Addiction and Mental Health. An eight-week group program was developed in response to
numerous requests for practical assistance from family members struggling to manage the needs of relatives
who were diagnosed with major depression and bipolar disorder. The goal of the group was to improve the
family's ability to cope with the situation, rather than to focus on the ill relative's condition.
Families expressed the need not only for information about how these disorders are understood and treated
but also for practical strategies and skills to better cope with their relatives at home.
Many of these families had been dealing with their relative's illness for many years. While family members
were expected to provide ongoing care and support, they lacked access to information about medications,
treatments or the prognosis of their relative's condition — even in cases where their relative consented to the
open exchange of information between the doctor and family members.
The model and content of this group series was developed after extensive review of the literature and
based on our conversations and clinical experiences with clients and family members. The series is based on
principles drawn from the models of group psychotherapy, psychoeducation and adult education. It is impor-
based on our conversations and clinical experiences with clients and family members. The series is based on
for every issue that may arise from group discussions. Depending on the constitution of each group
(spouse/parents/siblings), different themes will arise and can be integrated into the group process. While
VII
the literature is well-developed in the area of psychoeducational interventions for families of people with
schizophrenia, the literature is less developed for the disorders of major depression and bipolar disorder.
The absence of resources in this area was reflected by the overwhelming response from families in the
community once the program was launched.
WHICH FAMILIES ARE APPROPRIATE?
This series was developed for adult family members who are dealing with adults (over age 18) diagnosed with
mood disorders. Participants may be parents of adult children, partners or spouses, adult siblings, step-family
members and even close friends who are part of the affected person's support system.
The model format is designed to be flexible.
This series can be presented over an eight-week period, which is both cost-effective and allows time for
participants to establish a supportive environment and group cohesion. For therapists who are providing these
groups for the first time, however, the content may appear overwhelming to present in only eight weeks.
For this reason, we have developed a model that can easily be adapted and presented over a longer period,
such as 10 or 12 weeks. In these cases, Groups 4 (communication strategies), 5 (problem management) and
6 (crisis management) can each be extended over two sessions.
Depending on the individual style of each leader and the needs of the community, groups may run for
90 minutes without a break, or for two hqurs with a short break.
GROUP SIZE
Ideally, the group should include 12 group members and two therapists. However, groups can also be highly
effective with only eight or 10 members, or up to 16 members. Most members are extremely motivated and
attend the complete series; however, dropout will sometimes occur due to unforeseen circumstances. For this
reason, groups should start with at least 12 participants to avoid the possibility of an overly small group.
Optional follow-up group
You may also choose to hold a follow-up group approximately three months after the final group meeting.
The follow-up session offers group members an opportunity to meet again and discuss how they have coped
with their individual situations since the end of the formal series. It also encourages group members to
stay in contact after the series closes, either through informal friendships or by means of a more formal
continuing self-help group.
Previous experience facilitating groups
All leaders will need experience with managing and guiding group process, including an understanding of the
stages of group process, dynamics of groups and the role of the facilitator in this process. The integration
of practical information and processing the emotional reactions/responses of group members can be
challenging. Factual information can often trigger strong and painful emotional responses in parents and
partners. Disclosures by group members can lead to powerful exchanges between group members or between
members and leaders. As a result, you must be skilled in managing and directing group dynamics before
launching a series that requires the integration of both content and process. You should feel comfortable
directing the group process to ensure that the content is covered throughout the series.
If you lack experience facilitating psychoeducational groups you should consider using the longer format (two-
hour sessions held over 10 to 12 weeks), which allows more time for content and discussion. Ideally, the
Vlll
model requires two group therapists to facilitate the group; however, one experienced therapist can provide
the service with the assistance of a family member who has had training and orientation in the running of
psychoeducation groups, perhaps through a self-help organization.
In some areas, two therapists may offer the group in the first series, and a particularly effective family par-
ticipant may be identified to receive some further orientation, and then work with the therapist to facilitate
the next group series.
KNOWLEDGE BASE OF GROUP LEADERS
Typically, clients who attend psychoeducational programs tend to be welt-read and well-informed before
attending these groups. As a result, most group members are not seeking general information but rather to
discuss various contradictions found in the literature, self-help materials or on the Internet.
This manual provides the core content required for groups in which participants have both basic and advanced
knowledge. You should also be prepared do background reading on mood disorders in order to remain
current regarding recent developments in the literature.
RECRUITMENT OF GUEST LECTURER FOR MEDICATION INTERVENTIONS (GROUP 2)
Although this manual can be presented by two consistent group facilitators, you will need to recruit someone
with expertise in medication treatments to conduct Group 2 (a one-hour information session for families). This
person may be a psychiatrist, pharmacist, clinical nurse specialist or registered nurse who has experience in
the area of mood disorder medications. Please refer to Group 2 (p. 31) for more details. Because it may take
some time to locate an appropriate individual, arrange this early in the planning process.
ADDITIONAL REFERENCES
Although comprehensive references are listed at the end of this manual, it is important to note that the
literature is ever-changing. As a result, you will need to continuously update your knowledge by visiting
academic libraries, as well as researching community resources in and around your area.
GROUPS FOR ETHNO-RACIAL/ETHNO-CULTURAL POPULATIONS
This manual provides the core elements to include in a psychoeducation series. If your group includes relatives
from specific ethno-racial and ethno-cultural populations, you will need to be sensitive to the specific needs
of these groups. For example, in some cultures, it is difficult to discuss mental illness because it is not consi-
dered to legitimately exist. Early in the process, group members may need the opportunity to address this issue
and to address their subsequent discomfort even attending the group.
In these cases, you will need to be reasonably knowledgeable about specific cultural groups and how the
manual content should be modified or adapted to meet their needs. This might involve adding or omitting con-
tent and substituting more appropriate role-plays.
Consultation with people from the particular cultural group, or consultation with people who are knowledge-
able about the norms and values of the group, could facilitate the process.
IX
